Embolic Potential of Cardiac Tumors and Outcome After Resection

Cardiac Sarcoma Mimicking Libman-Sacks Endocarditis in a Patient with Systemic Lupus Erythematosus (SLE): A Case Report and Literature Review

We present the case of a 39-year-old woman who was diagnosed with SLE and antiphospholipid antibodies 8 years ago. The chief manifestations of her disease included low-grade fever and polyarthritis. Eight months before presentation, she experienced symptoms attributed to a flare of SLE, leading to an increase in immunomodulatory treatment with no improvement. She presented to the emergency room with acute onset of dyspnea. Clubbing of her fingers and toes was noted. When questioned, she reported the onset of clubbing 5 months earlier. A CTA was performed to rule out pulmonary embolism, which was excluded, although it revealed a severely damaged mitral valve with severe insufficiency and a large mass on the valve, protruding into the left atrium. Antibiotics were started, with a working diagnosis of infectious endocarditis; however, the severe mitral valve dysfunction lead to emergency mitral valve replacement, revealing an organized thrombus. She was treated with anticoagulation, with a working diagnosis of Libman-Sacks endocarditis, with no improvement. Additional immunosuppression failed to improve her symptoms. Enlargement of the thrombotic mass and an increased gradient across the prosthetic mitral valve led to repeat surgery, culminating in a diagnosis of high-grade sarcoma within the left atrial mass. We further discuss cardiac sarcoma and describe the occurrence of clubbing in patients with sarcoma. This case highlights the importance of interdisciplinary collaboration and the need for vigilant monitoring in refractory cases, particularly when atypical presentations arise.

Malignant cardiac neoplasms and associated malignancies over 16 years in the USA

BACKGROUND

Malignant cardiac neoplasms (MCNs), both primary and metastatic, are rare with few epidemiologic studies.

METHODS

This retrospective study used the Healthcare Utilization Project/Nationwide Inpatient Sample database from 2002 to 2018 to evaluate the co-occurrences with other malignancies, and mortality of MCNs in the USA.

RESULTS

The data contained 7207 weighted discharges of MCN. Median patient age was 51.4 years, 52.29 % were male, in-hospital mortality was 10.51 %, mean cost of hospitalization was $34,280 USD. Lung, mediastinum, and airways were the most common primary cancers associated with metastatic MCN.

CONCLUSIONS

MCN are rare in the USA, however they carry a high in-hospital mortality, high morbidity, and hospital cost.

Tumor Embolic Stroke: The Importance of Pathological Assessment of Clots after Thrombectomy

While tumor emboli are a rare cause of stroke in cancer patients, they highlight the importance of gross observations and pathological assessments in the evaluation of clots. In this case report, a 70-year-old male with type 2 diabetes mellitus and coronary artery disease presented with acute left-sided weakness. He was clinically diagnosed with stroke and given alteplase at 1.5 h from last known normal. He then underwent CT angiography that showed right internal carotid artery occlusion and immediate thrombectomy. The recovered clot was white and lipid-like; due to its atypical appearance, it was sent for pathological assessment, where it was shown to bear features of malignancy. Subsequent imaging identified masses indicating malignancy in the left gluteus, right pleural hilum, and spine. Tumor embolic stroke is a rare pathology. Embolic diseases such as strokes and pulmonary embolisms are common in patients with cancer. Embolic stroke of undetermined source (ESUS) represents a significant portion of cancer strokes. Tumor emboli, though rare, may be an underappreciated source of ESUS in cancer patients. We intend for this case to demonstrate the value of pathological assessment for atypical thrombi as well as highlight the etiology of tumor embolic strokes.

Epidemiology of Cardiac Myxoma in the Kingdom of Bahrain

BACKGROUND

Cardiac myxomas (CM) are the most prevalent type of primary cardiac tumour. The majority of primary cardiac tumours, including CM, are found to be benign. In the context of this study, the objective was to investigate and analyse the experience of CM over a period of 10 years, specifically in Bahrain. By examining this particular subset of cardiac tumours, valuable insights can be gained regarding their prevalence, clinical presentation, diagnostic methods, treatment approaches, and outcomes in the Bahraini population.

METHODS

We retrospectively evaluated the medical records of 20 patients who presented with CM at the Mohammed bin Khalifa bin Salman Al Khalifa Specialist Cardiac Centre in the Kingdom of Bahrain from January 2010 to January 2021. All patients had transthoracic echocardiography to establish a preoperative diagnosis. All of the patients underwent an operation using the median sternotomy, and a histopathology examination confirmed the final diagnosis.

RESULTS

The mean age at the time of presentation was 57 (± 18.1) years, ranging from 17 to 80 years, and 55% (12 patients) were female. Dyspnea (n=8, 40%) and peripheral embolism (n=4, 20%), which include cerebrovascular accidents and acute monocular vision loss, were the most frequently observed symptoms. The largest diameter of the myxoma was 5.1 cm (±1.7). The left atrium was the predominant location for myxoma formation (n=16, 80%), with the majority of the myxomas attached to the atrial septum.

CONCLUSION

CM poses a significant risk of cardiac and systemic complications. Early detection and timely gross-complete resection result in excellent early and long-term outcomes.

Cardiac papillary fibroelastoma: a rare cause of ST-segment elevation myocardial infarction: a case report

Introduction and importance

Primary tumors of the heart are extremely rare occurrences. Among them, cardiac papillary fibroelastoma (CPF) is the second most common type. Although these tumors are usually benign, they can pose a risk of embolization, which may lead to severe complications like sudden death or embolization affecting the neurological, systemic, or coronary vasculature. Such complications can be life-threatening.

Case presentation

In this report, the authors present the case of a 68-year-old woman who experienced ST-segment elevation myocardial infarction due to embolization from a large papillary fibroelastoma. To address the issue, the authors performed a minimally invasive surgical removal and resection of the aortic valve, followed by a histological examination to confirm the diagnosis.

Clinical discussion

This case report discusses a rare occurrence of myocardial infarction caused by tumor embolization from a CPF. The patient presented with complete blockage of a coronary artery in the absence of atherosclerotic disease. Through a comprehensive workup, including transesophageal echocardiography, the CPF was identified as the source of embolization. Surgical resection of CPFs is curative, and recurrence has not been documented. Clinicians should consider CPFs in cases of coronary artery occlusion without atherosclerotic disease and employ transesophageal echocardiography for diagnosis. Prompt surgical intervention leads to an excellent prognosis and prevents recurrent embolization.

Conclusion

This report emphasizes the importance of recognizing the potential complications associated with papillary fibroelastoma-induced embolization to the coronary arteries and highlights the need to mitigate the risk of such complications occurring.

Timing of Intervention for Left Ventricular Mass in the Setting of Acute Obstructive Coronary Artery Disease

•Comorbid need for antiplatelet therapy complicates intracardiac mass management. •Noninvasive mass diagnosis is invaluable for patients at high operative risk. •Guidelines for timing of intervention on masses are currently not well defined.

Neurologic Complications of Cardiac and Pulmonary Disease

OBJECTIVE

The heart and lungs work as a functional unit through a complex interplay. The cardiorespiratory system is responsible for the delivery of oxygen and energy substrates to the brain. Therefore, diseases of the heart and lungs can lead to various neurologic illnesses. This article reviews various cardiac and pulmonary pathologies that can lead to neurologic injury and discusses the relevant pathophysiologic mechanisms.

LATEST DEVELOPMENTS

We have lived through unprecedented times over the past 3 years with the emergence and rapid spread of the COVID-19 pandemic. Given the effects of COVID-19 on the lungs and heart, an increased incidence of hypoxic-ischemic brain injury and stroke associated with cardiorespiratory pathologies has been observed. Newer evidence has questioned the benefit of induced hypothermia in patients with out-of-hospital cardiac arrest. Further, global collaborative initiatives such as the Curing Coma Campaign are underway with the goal of improving the care of patients with coma and disorders of consciousness, including those resulting from cardiac and pulmonary pathologies.

ESSENTIAL POINTS

The neurologic complications of cardiorespiratory disorders are common and present in various forms such as stroke or hypoxic and anoxic injury related to cardiac or respiratory failure. With the emergence of the COVID-19 pandemic, neurologic complications have increased in recent years. Given the intimate and interdependent dynamics of the heart, lungs, and brain, it is crucial for neurologists to be aware of the interplay between these organs.

Long-term outcomes after minimal right lateral thoracotomy for the resection of cardiac tumors

OBJECTIVES

Cardiac tumors are a rare and heterogeneous entity, with a cumulative incidence of up to 0.02%. This study aimed to investigate one of the largest patient cohorts for long-term outcomes after minimally-invasive cardiac surgery using right-anterior thoracotomy and femoral cardiopulmonary bypass (CPB) cannulation.

METHODS

Between 2009 and 2021, patients who underwent minimally-invasive cardiac tumor removal at our department were included. The diagnosis was confirmed postoperatively by (immune-) histopathological analysis. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed.

RESULTS

Between 2009 and 2021, 183 consecutive patients underwent surgery for a cardiac tumor at our department. Of these, n = 74 (40%) were operated on using a minimally-invasive approach. The majority, n = 73 (98.6%), had a benign cardiac tumor, and 1 (1.4%) had a malignant cardiac tumor. The mean age was 60 ± 14 years, and n = 45 (61%) of patients were female. The largest group of tumors was myxoma (n = 62; 84%). Tumors were predominantly located in the left atrium in 89% (n = 66). CPB-time was 97 ± 36min and aortic cross-clamp time 43 ± 24 min s. The mean hospital stay was 9.7 ± 4.5 days. The perioperative mortality was 0%, and all-cause mortality after ten years was 4.1%.

CONCLUSION

Minimally-invasive tumor excision is feasible and safe, predominantly in benign cardiac tumors, even in combination with concurrent procedures. Patients who require cardiac tumor removal should be evaluated for minimally-invasive cardiac surgery at a specialized center, as it is highly effective and associated with good long-term survival.

Diagnosis and Management of Cardioembolic Stroke

OBJECTIVE

Cardioembolic stroke accounts for nearly 30% of ischemic strokes. Prompt diagnosis of the underlying mechanism may improve secondary prevention strategies. This article reviews recent randomized trials, observational studies, case reports, and guidelines on the diagnosis and treatment of cardioembolic stroke.

LATEST DEVELOPMENTS

Several pathologies can lead to cardioembolic stroke, including atrial fibrillation, aortic arch atheroma, patent foramen ovale, left ventricular dysfunction, and many others. Secondary stroke prevention strategies differ across these heterogeneous mechanisms. In addition to medical treatment advances such as the use of direct oral anticoagulants in patients with atrial fibrillation, surgical treatments such as closure of patent foramen ovale have been shown to reduce the risk of recurrent stroke in select patients. Furthermore, left atrial appendage occlusion is a promising strategy for patients with atrial fibrillation who are candidates for short-term oral anticoagulation therapy but not long-term oral anticoagulation therapy.

ESSENTIAL POINTS

A thorough diagnostic evaluation is essential to determine cardioembolic causes of stroke. In addition to risk factor management and lifestyle modifications, identification and targeting of the underlying cardioembolic stroke mechanisms will lead to improved stroke prevention strategies in patients with cardioembolic stroke.

Clinical features, risk factors and survival in cardiac myxoma-related ischemic stroke: A multicenter case-control study

BACKGROUND

Cardiac myxoma (CM) is an important etiology of stroke in young adults, but studies on CM-related ischemic stroke (CM-IS) are limited and conflicting. Hence, we investigated clinical characterizations, risk factors of CM-IS, and short-term survival after surgical resection.

METHODS

We performed a retrospective analysis of data from all CM patients at three referral management centers and conducted follow-up examination.

RESULTS

Among 414 CM patients, 402 were recruited for further analysis, including 54 patients with CM-IS and 348 patients with CM without stroke (Non-stroke). In the acute phase, patients presented with NIHSS 3 (interquartile range: 0-10) and clinical presentation comprising neurological, cardiac and constitutional symptoms. Multivariate analysis showed that the factors associated with an increased risk of CM-IS were tumor width < 30 mm [OR = 2.652, 95% CI: 1.061-6.627, P = 0.037], tumors with high-mobility (OR = 2.700, 95% CI: 1.357-5.371, P = 0.005), thrombus on the tumor surface (OR = 1.856, 95% CI: 1.003-3.434, P = 0.049), and lower B-type natriuretic peptide (BNP) levels (OR = 0.995, 95% CI: 0.989-0.999, P = 0.047). The overall three-year survival rate was 95.7% (95% CI: 94.9-96.5) in CM-IS patients who underwent surgery.

CONCLUSIONS

CM-IS patients had mild or moderate neurologic deficits with various presentations at disease onset. Narrower tumor width, tumors with high-mobility, thrombus on the tumor surface, and lower BNP levels are potential predictors of CM-IS development. Surgical removal of CM is safe and efficacious in patients with CM-IS.

Risk factors assessment and a Bayesian network model for predicting ischemic stroke in patients with cardiac myxoma

Objective

This study aims to identify relevant risk factors, assess the interactions between variables, and establish a predictive model for ischemic stroke (IS) in patients with cardiac myxoma (CM) using the Bayesian network (BN) approach.

Methods

Data of patients with CM were collected from three tertiary comprehensive hospitals in Beijing from January 2002 to January 2022. Age, sex, medical history, and information related to CM were extracted from the electronic medical record system. The BN model was constructed using the tabu search algorithm, and the conditional probability of each node was calculated using the maximum likelihood estimation method. The probability of each node of the network and the interrelationship between IS and its related factors were qualitatively and quantitatively analyzed. A receiver operating characteristic (ROC) curve was also plotted. Sensitivity, specificity, and area under the curve (AUC) values were calculated and compared between the BN and logistic regression models to evaluate the efficiency of the predictive model.

Results

A total of 416 patients with CM were enrolled in this study, including 61 with and 355 without IS. The BN model found that cardiac symptoms, systemic embolic symptoms, platelet counts, and tumor with high mobility were directly associated with the occurrence of IS in patients with CM. The BN model for predicting CM-IS achieved higher scores on AUC {0.706 [95% confidence interval (CI), 0.639-0.773]} vs. [0.697 (95% CI, 0.629-0.766)] and sensitivity (99.44% vs. 98.87%), but lower scores on accuracies (85.82% vs. 86.06%) and specificity (6.56% vs. 11.48%) than the logistic regression model.

Conclusion

Cardiac symptoms, systemic embolic symptoms, platelet counts, and tumor with high mobility are candidate predictors of IS in patients with CM. The BN model was superior or at least non-inferior to the traditional logistic regression model, and hence is potentially useful for early IS detection, diagnosis, and prevention in clinical practice.

An extensive surgical resection in stage T4 small cell lung cancer with cardiac invasion: A case report and literature review

Introduction and importance

We report a rare case of a patient with a mass involving both the hilum and the heart, but its specific nature could not be determined. SCLC was confirmed by postoperative pathology. It revealed that radical surgical resection for T4 SCLC should be considered an important part of multimodality treatment.

Case presentation

A 49-year-old gentleman complained of mild chest tightness for a week. Two large mass lesions were detected on CECT in the left atrium and left hilum. After an MDT discussion, an extended resection was recommended. Postoperative pathology denoted a complete excision with no residuals and negative lymph nodes.

Clinical discussion

Due to the rarity of lung metastases to the heart, it is vital to determine the homology between the hilar mass and the cardiac mass. Based on this, simultaneous surgical treatment is done and it is very beneficial for patients by eliminating those hazards, such as acute mechanical cardiac obstruction, and cardiac embolism. Our literature review demonstrates that the SCLC tumour progresses rapidly after cardiac metastasis, limiting the chance of a complete resection. Furthermore, complete resection of T4 tumours in NSCLC has been attempted many times, so it should also be tried on SCLC.

Conclusion

It is common for SCLC tumours to progress rapidly once they havemetastasized to the heart. An aggressive operation such as radical resection can reduce tumor burdens, minimize the risk of sudden acute death and improve patient follow-up treatment, all of which may prolong the survival of patients.

•

In most cases, cardiac metastasis occurs in small-cell lung cancer with distant metastasis elsewhere. There are few cases in which there is no distant metastasis except lung and heart just like our case.

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Cases of extended resection of T4 stage NSCLC have been reported, but cases of extended resection of T4 stage SCLC are rare.

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We believe that the occurrence of cardiac metastasis in SCLC may indicate that the tumour enters the stage of accelerated growth. An extensive resection reduces the risks of embolism and cardiac pumping disorders brought by cardiac tumours to patients and is conducive to better acceptance of radiotherapy and chemotherapy in later stages.

Benign and malignant cardiac masses: long-term outcomes after surgical resection

BACKGROUND

Cardiac tumors represent a rare and heterogenous pathologic entity, with a cumulative incidence of up to 0.02%. This study aimed to investigate one of the largest patient cohorts published for clinical presentation and long-term outcomes after surgical resection.

RESEARCH DESIGN

Between 2009 and 2021, 183 consecutive patients underwent surgery for tumor excision in our center. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed. The diagnosis was confirmed postoperatively by histology and Immunohistochemical investigations. Kaplan-Meier curves assessed survival, and the Cox, proportional hazards model, was used to identify prognostic factors for overall survival.

RESULTS

This series included 183 consecutive patients; most (n=169, 92.3%) were diagnosed with benign cardiac masses. The mean age of patients was 60 ± 16 years, and 48% (n=88) were females. The largest group of tumors is represented by myxoma (n = 98; 54%). The most common malignant tumor was sarcomas (n = 5; 2.7%). The mean hospital stay was 11 ± 6.5 days, and all-cause mortality after ten years was 14%.

CONCLUSION

Surgery represents the gold standard in treating primary cardiac tumors; in benign tumors, it is highly effective and curative, whereas, in malignant tumors, it remains associated with more prolonged survival.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Cardiac Myxoma: A Case Series and Pooled Analysis

Background and Purpose

Acute ischemic stroke (AIS) is a major life-threatening consequence of cardiac myxoma (CM) and leads to a poor prognosis. Although intravenous thrombolysis (IVT) is the first-line treatment for AIS, its efficacy and safety in CM-AIS have not been established. Currently, there are only limited data from case reports. Our study aimed to investigate the clinical characteristics of CM-AIS and evaluate the safety and efficacy of IVT for CM-AIS patients.

Methods

Fourteen CM-AIS patients who received IVT between January 2016 and December 2021 were identified from our multicenter stroke registry databases. Clinical, neuroimaging and outcome data were analyzed. We then performed a pooled analysis of the published literature from inception to December 2021.

Results

Of the 14 CM-AIS patients, nine were treated with IVT alone, and five were treated with bridging therapy (BT). The median age was 51.5 years, and 57.1% were female. The median onset-to-needle time was 160 min. The median National Institute of Health Stroke Score (NIHSS) decreased from 15.5 at presentation to 13 24 h after IVT. Very early neurological improvement (VENI) was observed in one patient. Hemorrhagic transformation (HT) was observed in five (35.7%) patients, and only one patient was symptomatic (7.1%). Three-month favorable outcomes were achieved in six patients (66.7%) who underwent IVT alone and three patients (60%) who received BT, which resulted in a total proportion of favorable outcomes of 64.3%. None of the patients died at 3 months follow-up. Forty-seven cases (15 BT patients) were included for the pooled analysis. The median NIHSS score was 16.5, and VENI was observed in 10 (21.3%) patients. HT was detected in 11 patients (23.4%), and four (8.5%) patients were symptomatic. Favorable outcomes at 3 months were achieved in 61.7% of patients, 56.3% of patients who underwent IVT alone, and 73.3% of patients who received BT. The 3-month mortality rate was 4.3%.

Conclusions

IVT is a potentially safe and efficient treatment for CM-AIS patients. Further studies with larger sample sizes are required to provide more evidence on the safety and efficacy of IVT and BT in CM-AIS patients.

Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies

The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.

Assessment of patients with a suspected cardioembolic ischemic stroke. A national consensus statement

OBJECTIVES

Several cardiovascular, structural, and functional abnormalities have been considered as potential causes of cardioembolic ischemic strokes. Beyond atrial fibrillation, other sources of embolism clearly exist and may warrant urgent action, but they are only a minor part of the many stroke mechanisms and strokes that seem to be of embolic origin remain without a determined source. The associations between stroke and findings like atrial fibrillation, valve calcification, or heart failure are confounded by co-existing risk factors for atherosclerosis and vascular disease. In addition, a patent foramen ovale which is a common abnormality in the general population is mostly an innocent bystander in patients with ischemic stroke. For these reasons, experts from the national Danish societies of cardiology, neurology, stroke, and neuroradiology sought to develop a consensus document to provide national recommendations on how to manage patients with a suspected cardioembolic stroke. Design: Comprehensive literature search and analyses were done by a panel of experts and presented at a consensus meeting. Evidence supporting each subject was vetted by open discussion and statements were adjusted thereafter. Results: The most common sources of embolic stroke were identified, and the statement provides advise on how neurologist can identify cases that need referral, and what is expected by the cardiologist. Conclusions: A primary neurological and neuroradiological assessment is mandatory and neurovascular specialists should manage the initiation of secondary prophylactic treatment. If a cardioembolic stroke is suspected, a dedicated cardiologist experienced in the management of cardioembolism should provide a tailored clinical and echocardiographic assessment.

Benign Cardiac Neoplasms in the United States: A Thirteen-Year Review

Cardiac neoplasms are uncommon tumors. For epidemiological purposes, they can be divided into benign and malignant subtypes, with the former occurring at a significantly higher rate than the latter. Due to their uncommon nature, there are few data-driven studies examining the characteristics and trends of benign cardiac neoplasms. Our retrospective HCUP-NIS data review purports to illuminate some of the trends surrounding benign cardiac neoplasms and their associated co-occurrences. The data consisted of 482,872,274 weighted discharges. There were 45,568 weighted discharges that included a benign cardiac neoplasm. Benign cardiac neoplasms were more often observed in women (64.33%), and the average age was 63.8 years. The most common cardiovascular co-occurrences in patients with benign cardiac neoplasm were atrial tachyarrhythmias (28.93%), heart failure (19.61%), and embolic events such as stroke, myocardial infarct, or pulmonary embolism (19.82%). Other co-occurrences included pulmonary hypertension (7.55%), ventricular arrhythmias (3.23%), and other EKG abnormalities (3.70%). Procedures were numerous in patients with benign cardiac neoplasms. 43% of patients with this diagnosis had some form of cardiac surgery during their hospitalization. Overall, this study found low incidence of benign cardiac neoplasms in the USA during this 13-year study period. However, in the presence of benign cardiac neoplasms, our study showed that cardiovascular co-occurrences are not uncommon and may help to illuminate this otherwise rare diagnosis.

Small cell carcinoma presenting as a biatrial mass with obstructive physiology: a case report

Background

Small cell carcinoma is a highly aggressive and often fatal cancer that most commonly arises in the lung, although it can occasionally arise from other sites, such as the gastrointestinal tract, prostate or cervix. Cardiac involvement, however, is extremely uncommon and therefore has been poorly documented in the literature.

Case presentation

We describe a rare case of a 31-year-old male with small cell carcinoma presenting as a massive, 15-cm cardiac tumor invading the bilateral atria, interatrial septum, and pericardium without an apparent primary malignancy on PET CT and cardiac MRI. With extensive tissue necrosis, traditional methods of obtaining a right atrial endomyocardial biopsy via internal jugular venous access failed and a diagnosis was made via endoscopic ultrasound guided transesophageal fine needle aspiration of the left atrial mass. Due to the extensive tumor invasion, the patient was not a suitable candidate for surgical resection, debulking, or heart transplant. The patient was treated with etoposide, carboplatin, atezolizumab, and radiation therapy with initial monitoring in the intensive care unit due to concern that tumor lysis may cause rapid cardiac decompensation. Unfortunately, 4 months after chemoradiation therapy, the malignancy progressed and the patient passed away 6 months after the initial diagnosis.

Conclusion

We describe a rare occurrence of small cell carcinoma presenting as a massive cardiac tumor without apparent primary malignancy. This case demonstrates useful alternative diagnostic strategies and treatment considerations for patients presenting with a rare cardiac mass.

Cerebrovascular manifestations of tumors of the heart

Primary tumors of the heart, most commonly myxoma, are an uncommon cause of ischemic stroke and intracranial aneurysms. The tumors may occur in any age group but are most frequently detected in middle-aged persons with an atypical or cryptogenic stroke. While some patients will have a history of cardiac or constitutional symptoms, in many cases ischemic stroke will be the initial manifestation of the cardiac mass. Myxomas are the most common cardiac tumors, and valvular fibroelastoma is also a potential cardiac cause of stroke. Among patients with stroke, the most common location for a myxoma is the left atrium. Elevations of inflammatory markers provide clue for a myxoma. Cardiac imaging is the most definitive diagnostic study. Treatment centers on surgical removal of the cardiac mass may be curative.

Cerebral embolism due to left atrial myxoma in a patient presenting with chest pain and ST-segment elevation: a case report

Background

Myocarditis is an uncommon, potentially life-threatening disease that presents with a wide range of symptoms. In acute myocarditis, chest pain (CP) may mimic typical angina and also be associated with electrocardiographic changes, including an elevation of the ST-segment. A large percentage (20-56%) of myxomas are found incidentally.

Case summary

A 62-year-old female presenting with sudden onset CP and infero-lateral ST-elevation in the electrocardiogram. The diagnosis of ST-elevation myocardial infarction was presumed and administered tenecteplase. The patient was immediately transported to a percutaneous coronary intervention centre. She complained of intermittent diplopia during transport and referred constitutional symptoms for the past 2 weeks. Coronary angiography showed normal arteries. The echocardiogram revealed moderate to severe left ventricular systolic dysfunction due to large areas of akinesia sparing most of the basal segments, and a mobile mass inside the left atrium attached to the septum. The cardiac magnetic resonance (CMR) suggested the diagnosis of myocarditis with concomitant left atrial myxoma. The patient underwent resection of the myxoma. Neurological evaluation was performed due to mild vertigo while walking and diplopia in extreme eye movements. The head magnetic resonance imaging identified multiple infracentimetric lesions throughout the cerebral parenchyma compatible with an embolization process caused by fragments of the tumour.

Discussion

Myocarditis can have various presentations may mimic acute myocardial infarction and CMR is critical to establish the diagnosis. Myxoma with embolic complications requires emergent surgery. To the best of our knowledge, this is the first case reported in the applicable literature of a myxoma diagnosed during a myocarditis episode.

Risk factors of embolism for the cardiac myxoma patients: a systematic review and metanalysis

Background

The risk factors contributing to embolism in cardiac myxoma (CM) are yet controversial. This systematic review and meta-analysis aimed to clarify the risk factors of embolism for the CM patients.

Methods

PubMed, Embase, Cochrane library, Web of Science, China National Knowledge Infrastructure, Wan Fang, and Wei Pu databases were searched from inception to June 2019. Statistical analysis was conducted using Stata version 14.0. The pooled odds ratio or mean difference with 95% confidence interval was estimated for each risk factor.

Results

Herein, 12 studies, encompassing 1814 patients, were included. The pooled results suggested that New York Heart Association (NYHA) class I/II (P < 0.01), hypertension (P = 0.03), irregular tumor surface (P < 0.01), tumor in atypical location (P = 0.01), narrow base of tumor (P < 0.01), and increased fibrinogen (FIB) (P < 0.01) are significant risk factors of embolism in CM patients. However, sex, age, body mass index, smoking, left ventricular ejection fraction, diabetes, hyperlipidemia, atrial fibrillation, valvular heart disease, coronary heart disease, tumor size, platelet count, white blood cells, and hemoglobin were not associated with embolism (all P > 0.05).

Conclusions

NYHA class (I/II), hypertension, irregular tumor surface, atypical tumor location, the narrow base of tumor, and increased FIB were significant risk factors of embolism in CM patients. For CM patients with these factors, early surgery might be beneficial to prevent embolism.

Disappearing "Myxoma": Left Atrial Thrombus Masquerading as a Myxoma

Intracardiac masses can be challenging to differentiate by echocardiography. We present a case of several intracardiac masses with echocardiographic features of both thrombi and myxoma in a patient with heart failure symptoms. The masses were confirmed to be thrombi after complete resolution on repeat echocardiography following anticoagulation. Echocardiography complements the history and physical exams in diagnosing intracardiac masses but may present a diagnostic challenge when features are not pathognomonic. Follow up imaging after anticoagulation should be standard of care to avoid unnecessary surgeries when the diagnosis of a cardiac mass is uncertain.

Crossing Boundaries: A Rare Case of Cardiac Dysfunction

Cardiac tumors are relatively rare. Secondary cardiac tumors are by far more common than primary cardiac tumors. Cardiac involvement may occur secondary to hematogenous metastases, direct invasion, or tumor growth into the venous system and extension into the right atrium. Patients can present with a spectrum of conditions, including embolization, obstruction of ventricular outflow tracts, direct invasion of myocardium causing impaired myocardial function, invasion of surrounding tissue, interference with valvular function causing valvular regurgitation, or constitutional non-specific signs and symptoms. Imaging modalities are essential for diagnosis. Management is mostly surgical, but can include other medical strategies as well. We present a case of a 65-year-old male with hepatocellular carcinoma with direct invasion to the heart through the venous system.

Enigma of recurrent strokes with literature review

Metastatic tumors are the most common tumors affecting the heart. Primary tumors are rare, with myxomas being the most common of the primary cardiac tumors. The incidence of primary cardiac tumors is 0.02%, about 200 cases has been reported in 1 million autopsies. Most of primary cardiac tumors have been detected incidentally on diagnostic modalities: computed tomography (CT), cardiac magnetic resonance imaging (MRI), or echocardiography. Majority of primary-origin cardiac tumors are benign, of which the most common type of primary tumor is cardiac myxoma. Fibroelastoma is a rare benign tumor and the 2nd most common cause of primary cardiac tumors. In the past fibroelastoma has been detected on autopsy findings. With the development of more advanced imaging modalities fibroelastoma is more frequently detected as a cause of stroke, myocardial infarction (MI), angina episodes, and systemic embolization. Echocardiogram is the best diagnostic modality to diagnose primary cardiac tumors although transthoracic echocardiogram (TTE) can miss primary cardiac tumors; transesophageal echocardiography (TEE) has been more labeled more accurate in the diagnosis of primary cardiac tumors. We present here a case of a 21-year-old male with the history of multiple strokes secondary to cardiac papillary fibroelastoma (CPF).

A Left Ventricular Papillary Fibroelastoma Presenting as an Acute Coronary Syndrome

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PFEs are benign cardiac tumors with possible catastrophic embolic complications.

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Echocardiography is the initial modality of choice in their diagnosis.

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Surgical excision is warranted in symptomatic cases or if embolization is likely.

Atrial myxoma presenting as infective endocarditis

A 23-year-old Asian student presented to our service with a 1-month history of fever, weight loss of 10 kg, night sweats, fatigue and general malaise. He was previously well with no significant medical or family history. He had a low-grade pyrexia and cardiac auscultation revealed a diastolic murmur consistent with 'tumour plop'. He had no sequelae of endocarditis. He had low-grade pyrexia of 37.7°C, and ECG showed sinus tachycardia at 130 bpm. He had raised inflammatory markers and was started on broad spectrum antibiotics. Blood cultures grew Streptococcus viridans twice. Transthoracic and transo-oesophageal echocardiography revealed a large mobile mass attached to the interatrial septum, suspicious for atrial myxoma, flopping into the left ventricle but not causing left ventricular outflow tract obstruction. All valves looked normal in appearance. He was treated with antibiotics for 2 weeks until inflammatory markers normalised. The patient was referred for cardiothoracic surgery where a large atrial myxoma (5 cm×3 cm) was excised just superior to the mitral valve. It had areas of necrosis and was colonised with S. viridans He had an unremarkable postoperative course and made a complete recovery.

Outcomes following embolization in patients with cardiac myxoma

BACKGROUND

Cardiac myxomas are the most frequent primary benign intracardiac tumors. We reviewed our 27-year experience to evaluate factors associated with an embolism in patients with cardiac myxomas and their long-term outcomes.

METHODS

A retrospective review identified 99 patients with cardiac myxomas between 1985 and 2012. Tumors were divided into two groups based on their gross external features. Tumors with a smooth regular border and a solid consistency were classified as solid; papillary myxomas were characterized by an irregular and gelatinous exterior with friable, soft consistency. The patients were classified into embolic and non-embolic groups to focus on embolic events.

RESULTS

Mean age at surgery was 49.8 ± 16 years. There were 92 left atrial myxomas (92.9%)_. Embolization was observed in 25 patients (25.3%) before surgery. Three variables were associated with an embolic event, small tumor size (odds ratio [OR] = 4.36 P = 0.037 confidence interval [CI] 95% 0.534-0.980), atrial fibrillation (OR = 10.119 P = 0.001 CI 95% 0.021-0.397), and papillary-type pathology (OR = 11.544 P = 0.001 CI 95% 0.033-0.399). Tumor pathology or the presence of embolization prior to surgery had no effect on operative mortality or long-term survival.

CONCLUSIONS

Embolization of cardiac myxomas is more likely to occur in papillary-type tumors, that are smaller in size and in patients presenting with preoperative atrial fibrillation. However, the presence of embolization at the time of surgery does not increase operative morbidity or mortality or affect long-term survival.

Outcomes of surgical treatment in 115 patients with primary cardiac tumours: a 15-year experience at a single institution

Background

Primary cardiac tumours are rare, and few studies have examined large samples. The aim of this study was to review a single institution's 15 years of experience with primary cardiac tumours.

Methods

We conducted a retrospective analysis of 119 consecutive patients admitted to the Nanjing Drum Tower Hospital from April 2002 to January 2017. Five patients declined surgery due to illness or for financial reasons, and one patient underwent a second operation due to tumour recurrence 10 years after the first operation. In total, 115 patients underwent surgery. The surgeons used median sternotomy and a right atrial approach to complete the gross total resection. The patients were separated into three groups according to their tumour pathology (myxomas, other benign tumours, or malignant tumours). A total of 84 patients were followed up for an average of 34.8±31.2 months (range 2-141 months).

Results

The sites of the cardiac tumours included the left atrium (n=93, 80.1%), right atrium (n=14, 14.0%), left ventricle (n=2, 1.7%), valves (n=7, 6.0%), and other sites (n=1, 0.8%). According to the postoperative pathology, 99 (86.0%) tumours were classified as myxomas, 8 (7.0%) were other types of benign tumours, and 8 (7.0%) were malignant tumours. Patients with malignant tumours had a longer surgical time (P=0.035) and postoperative hospitalization time (P=0.009). Patients with myxoma tumours exhibited better 5-year survival than patients with malignant tumours (95.7% vs. 57.1%, P<0.001).

Conclusions

In the Chinese population, the incidence of primary cardiac tumours is mainly attributable to myxomas. Gross total resection is a safe and effective treatment for both benign and malignant tumours. Long-term survival is satisfactory for benign tumours but low for malignant tumours, and a risk of recurrence exists. Postoperative chemotherapy or radiotherapy may be needed to achieve better outcomes.

Giant Left Atrial Myxoma Masquerading as Cough-Syncope Syndrome

Left atrial myxomas are the most common type of benign primary cardiac tumor. Patients can present with generalized symptoms, such as fatigue, symptoms from obstruction of the myxoma, or even embolization of the myxoma causing distal thrombosis. We describe a case with several-month duration of syncopal episodes that occurred after coughing and with exertion. Computed tomography of the chest showed a 6.1 cm by 4.5 cm mass in the left atrium, later evaluated with an echocardiogram. Cardiothoracic surgery removed the mass, and it was determined to be an atrial myxoma. It is important for an internist to be able to diagnose an atrial myxoma because of the risks associated with embolization and even sudden death as myxoma can block blood supply from atrium to ventricle.

Coronary Artery Embolism From a Blood Cyst of the Mitral Valve

Blood cysts are benign, congenital tumours of the heart endothelium, found most commonly on heart valves. Adult cases are rare, since most spontaneously regress with age. However, reports of symptomatic cases with embolic phenomena and valve dysfunction have been described. We present a case of a previously healthy 44-year-old woman with no cardiovascular risk factors who developed acute myocardial infarction caused by coronary artery embolism from a blood cyst of the anterior mitral valve leaflet.

Cardiac Lymphoma Presenting as Subacute Progressive Dyspnea: A Case Report and Review of the Literature on the Pathophysiology and Imaging of Intracardiac Tumors

•The case of a 64-year-old man with progressive dyspnea is presented. •Imaging revealed a large intracardiac mass invading the right chambers and the left atrium. •Extensive testing was conducted to reach the final diagnosis of primary cardiac B-cell lymphoma. •Primary cardiac lymphomas are very rare, especially in immunocompetent patients. •Due to inoperability, the patient underwent palliative chemotherapy.

Primitive Tumour of the Pulmonary Valve: Discussion of the Differential Diagnosis

There is a paucity of information concerning cardiac tumours of the pulmonary valve due to their rarity at this location. We report a case of a 47-year-old patient suffering from haemoptysis, asthenia, and acute kidney injury (AKI). A transthoracic echocardiography (TTE) revealed a mass on the pulmonary valve. Further diagnostic investigation was completed until he exhibited worsening hemodynamic instability. This case emphasizes the lack of information regarding the management of a pulmonary valve tumour.

Cardiac tumors: echo assessment

Cardiac tumors are exceedingly rare (0.001–0.03% in most autopsy series). They can be present anywhere within the heart and can be attached to any surface or be embedded in the myocardium or pericardial space. Signs and symptoms are nonspecific and highly variable related to the localization, size and composition of the cardiac mass. Echocardiography, typically performed for another indication, may be the first imaging modality alerting the clinician to the presence of a cardiac mass. Although echocardiography cannot give the histopathology, certain imaging features and adjunctive tools such as contrast imaging may aid in the differential diagnosis as do the adjunctive clinical data and the following principles: (1) thrombus or vegetations are the most likely etiology, (2) cardiac tumors are mostly secondary and (3) primary cardiac tumors are mostly benign. Although the finding of a cardiac mass on echocardiography may generate confusion, a stepwise approach may serve well practically. Herein, we will review such an approach and the role of echocardiography in the assessment of cardiac masses.

Altered Mental Status in a Child With an Unwitnessed Fall: A Case Report

We report a case of altered mental status in a 5-year-old boy who presented to the emergency department after presumed head trauma. A computed tomography head was conducted and its findings were normal, and the boy was discharged home. He returned the next day with persistent altered mental status and was found to have an abnormal MR brain suggestive of embolic strokes. An echocardiogram revealed a large atrial mass that was later confirmed by pathology to be an atrial myxoma. This is a unique and, to our knowledge, unreported presentation of a known but rare disease process in a pediatric patient.

Risk prediction for emboli and recurrence of primary cardiac myxomas after resection

BACKGROUND

Risk factors for embolism and recurrence of primary cardiac myxoma are not well established. This study aimed to assess the risk factors for embolism and recurrence of cardiac myxoma, as well as the survival of the patients.

METHODS

The medical records of 207 consecutive patients treated for primary cardiac myxoma between September 1988 and October 2014 were retrospectively analyzed. All diagnoses were pathologically confirmed. Data were collected to identify the risk factors influencing the prognosis.

RESULTS

Mean age at surgery was 44.2 ± 15.8 years. Operative mortality (within 30 days of the surgery) occurred in seven patients. Mean follow-up was 9.35 ± 6.55 years. Embolism occurred in 32 (15.5 %) patients before surgery. Multivariate analysis indicated that small (≤ 4.5 cm) myxoma (OR = 5.14; 95 % CI, 2.30-11.94; P < 0.0001) and soft, gelatinous myxoma (OR = 5.84; 95 % CI, 1.91-25.61; P = 0.001) were independently associated with the occurrence of embolism. Ten patients experienced recurrences. After excluding the patients who died within 30 days of surgery, survival was 92.7 % at 10 years. Age, sex, tumor size, cardiopulmonary bypass duration, aortic cross clamp duration, tumor appearance, and pre-operative embolism were not associated with early mortality. Multivariate analysis showed that multicentric myxomas were independently associated with recurrence (OR = 9.45, 95 % CI, 2.15-41.3, P = 0.004).

CONCLUSIONS

The surgical resection of primary cardiac myxoma is associated with excellent long-term survival. Tumors ≤ 4.5 cm and soft tumors were independent risk factors for embolism. Multicentric cardiac myxoma was an independent risk factors for recurrence of myxoma.

Metastatic Cardiac Angiosarcoma in a 26-Year-Old Male

BACKGROUND

Cardiac angiosarcomas are an extremely rare tumor with an incidence of only 0.056%. Diagnosing this rare tumor becomes even more difficult as the presentation of cardiac angiosarcomas varies based on anatomic location. Depending on the tumor's proximity to valves, symptoms may be more consistent with heart failure, while growth throughout the conduction system may produce arrhythmias.

CASE REPORT

We present the case of a young male with a significant tumor burden of cardiac angiosarcoma in his lungs whose symptoms included pleuritic chest pain and hemoptysis. This patient did not have the classic finding of right-sided heart failure; instead, his presenting complaint was hemoptysis.

CONCLUSION

The diagnostician's differential diagnosis must be broad when encountering common chief complaints, such as hemoptysis and chest pain.

Usefulness of contrast perfusion echocardiography for differential diagnosis of cardiac masses

The aim of this study was to assess the usefulness of contrast perfusion echocardiography in the differential diagnosis of different types of cardiac masses. Conventional echocardiography and contrast perfusion echocardiography were performed in 72 patients with cardiac masses. The degree of contrast enhancement of the mass and an adjacent section of myocardium after injection of contrast agent was determined by visual inspection and quantitative time-signal intensity curve analysis. The difference in maximal steady-state pixel intensity between the mass and the adjacent myocardium (ΔAmass-myocardium) was calculated. All masses had a pathologic diagnosis or resolved after anticoagulation. All 16 cardiac masses without enhancement on visual inspection were confirmed to be cardiac thrombi. Twenty-four masses with incomplete enhancement on visual inspection were recognized as benign tumors with validation methods. Of the 32 cardiac masses with complete enhancement, 30 were confirmed as malignant tumors and two as benign tumors with validation methods. The sensitivity and specificity of ΔAmass-myocardium in differentiating thrombi from tumors were 93% and 100%, respectively, and 100% and 97% in differentiating malignant tumors from benign tumors and thrombi. Both visual and quantitative assessment of degree of enhancement of cardiac masses in relation to the adjacent myocardium during contrast perfusion echocardiography had high diagnostic accuracy for differentiation of a thrombus from a tumor or a benign tumor from a malignant tumor.

Long-term follow-up of 82 patients after surgical excision of atrial myxomas

OBJECTIVES

Literature reporting on large patient groups with the long-term follow-up is limited due to the low incidence of myxomas. This single-centre, retrospective study reports on the long-term follow-up (e.g. complications, recurrence and survival) of a substantial patient group operated for cardiac myxomas.

METHODS

Patients were retrospectively selected from a prospectively obtained database comprising patients who had undergone cardiac surgery in the Catharina Hospital from 1990 onwards. Baseline characteristics and perioperative data were obtained from the database. In case of insufficient information, medical reports were analysed. The echocardiogram and clinical follow-up data were collected at outpatient clinics.

RESULTS

Eighty-two patients were included, of which 48 were females with a mean age of 61.3 years (±13.8). The main presenting symptom was dyspnoea (29.3%), followed by chest pain (24.4%), palpitations (19.5%) and embolism (15.9%). Atrial fibrillation was the most frequent complication; directly postoperative (22%) and at the long-term follow-up (26.3%). The follow-up was completed in 95.1%, with a mean echocardiographic follow-up time of 72 months and with a longest follow-up of almost 23 years. There were no myxoma recurrences. Thirteen patients (16.5%) deceased during the follow-up, with a mean time of 9 years after surgery.

CONCLUSIONS

Myxomas carry the risk of severe complications. Surgical excision is the only option of treatment and gives excellent early and long-term results. Recurrence rates are low in case of non-hereditary myxomas, even in case of irradical excision. The echocardiographic follow-up therefore could be called into question.

Benign Neoplasm of the Heart Increases the Risk of First Ischemic Stroke: A Population-Based Cohort Study

Objective:

The study aims to investigate the incidence of first ischemic stroke in patients with benign cardiac tumors who did or did not undergo operations.

Methods:

We used the National Health Insurance Research Database of Taiwan to conduct the research. The exposure cohort comprised 587 adult patients with benign cardiac tumors. Each patient was randomly frequency matched by age, index month, and index year with 10 participants from the general population who exhibited no history of benign cardiac tumors before the index date (control group). Cox's proportion hazard regression analyses were conducted to determine the relation between benign cardiac tumors and the risk of ischemic stroke.

Results:

Based on clinical diagnoses, the prevalence of benign cardiac tumors was 0·004%. Patients with benign cardiac tumors exhibited an increased risk of first ischemic stroke [adjusted hazard ratio: 1·77; (95% confidence interval, 1·20–2·63)], particularly at young ages (adjusted hazard ratio: 22·9, 95% confidence interval: 4·17–126·0). We observed no significant difference in the risk of ischemic stroke between men with and without benign cardiac tumors (adjusted hazard ratio: 1·29, 95% confidence interval: 0·63–2·63). Among patients with benign cardiac tumors, the adjusted hazard ratio of first ischemic stroke was 0·48 (95% confidence interval: 0·23–1·04) in the operation group compared with the nonoperation group.

Conclusion:

Younger patients (<50 years) with benign cardiac tumors exhibit an increased risk of first ischemic stroke.